|Year : 2020 | Volume
| Issue : 1 | Page : 11-16
A population-based study on the burden of tobacco-related cancers in Kamrup urban district cancer registry of Assam, India
Jagannath Dev Sharma, Debanjana Barman, Arpita Sharma, Manoj Kalita, Amal Chandra Kataki, Ranjan Lahon, Chinmoy Misra
Department Of Pathology, Principal Investigator, Population Based Cancer Registry-Kamrup (ICMR), Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
|Date of Submission||04-Nov-2019|
|Date of Decision||22-Sep-2020|
|Date of Acceptance||30-Sep-2020|
|Date of Web Publication||16-Nov-2020|
Medical Research Officer, Population Based Cancer Registry, Dr. B Borooah Cancer Institute, Gopinath Nagar, Guwahati 781 016, Assam
Source of Support: None, Conflict of Interest: None
Background: Tobacco use remains a serious and persistent national problem and is the leading preventable cause of cancer worldwide. At least 1.3 billion people worldwide use tobacco in some form and are responsible for causing mortality of approximately 6 million people annually from cancer and other diseases.
Materials and Methods: Data collection is active with participation of different sources including major hospitals, diagnostic centers, state referral board, and birth and death registration centers within registry area as cancer is not notifiable in India.
Results: In males, a total of 4794 cancer cases were registered in Kamrup urban district during the period from 2010 to 2014, out of which 2386 cases were tobacco-related cancers (TRCs), and in females out of 3767 cases, 944 were TRCs. In the North Eastern Region, head-and-neck cancer is common, and high use of tobacco is a risk factor in this region. The age-standardized rate (age-adjusted rate) per 100,000 population of TRCs in males is 99.9 and in females is 48.0.
Conclusion: Knowledge of the incidence and pattern of TRCs is of paramount importance in planning and implementing measures for primary prevention of tobacco use which is a major step in cancer control.
Keywords: Age-adjusted rate, crude rate, incidence, Kamrup urban district, mortality, tobacco-related cancers
|How to cite this article:|
Sharma JD, Barman D, Sharma A, Kalita M, Kataki AC, Lahon R, Misra C. A population-based study on the burden of tobacco-related cancers in Kamrup urban district cancer registry of Assam, India. J Med Soc 2020;34:11-6
|How to cite this URL:|
Sharma JD, Barman D, Sharma A, Kalita M, Kataki AC, Lahon R, Misra C. A population-based study on the burden of tobacco-related cancers in Kamrup urban district cancer registry of Assam, India. J Med Soc [serial online] 2020 [cited 2020 Dec 5];34:11-6. Available from: https://www.jmedsoc.org/text.asp?2020/34/1/11/300551
| Introduction|| |
Epidemiological studies have been carried out since ages linking the occurrence of cancer and human exposure to many environmental carcinogenic agents. One such study is the report of the US Surgeon General's Advisory Committee (USDHEW 1964) presenting the effect of cigarette smoking to lung cancer. Henceforth, several researches were carried out to find the etiological relation of various types of cancer to smoking and smokeless tobacco usage.
Cancer is one of the leading causes of morbidity and mortality worldwide, with an estimated 18.1 million new cases and 9.6 million deaths annually. Tobacco use remains a serious and persistent national problem and is the leading preventable cause of cancer worldwide. At least 1.3 billion people worldwide use tobacco in some form. Its consumption is responsible for causing mortality of approximately 6 million people annually from cancer and other diseases. These trends are increasing, and it is projected that tobacco will be responsible for the death of 8 million people annually in the next two decades. About 40% of all cancers are tobacco related, and 90% of the oral cancers are due to the use of tobacco.
In India, tobacco is consumed in myriad forms, which includes smoking as well as smokeless tobacco., Among all forms of tobacco use, smoking is the most addictive and most commonly used tobacco product across the globe. Smoked tobacco mainly consists of cigarettes and bidis (a local hand-rolled cigarette of dried temburni leaf containing coarse tobacco). An average loss of life expectancy of 2.4 years in men and 1 year in women associated with tobacco smoking has recently been reported. Tobacco is also chewed, sniffed, kept in the oral cavity, and reverse smoking. Smokeless tobacco contains around 28 known carcinogens. These include the nonvolatile alkaloid-derived tobacco-specific N-nitrosamine and N-nitrosamino acids as the major group while volatile tobacco-specific nitrosamines, volatile aldehydes, and some polynuclear agents have also been shown to be present in smokeless tobacco. Smokeless tobacco is one of the major risk factors associated with the high prevalence of head-and-neck and oral cancers.
As per the Global Adult Tobacco Survey (GATS) 2 (2016–2017) report, in India, 28.6% of adults aged 15 and above use tobacco in any form. Every fifth adult uses smokeless tobacco, and every tenth adult smokes tobacco. Among men, three most commonly used tobacco products are khaini, bidi, and gutkha, while in women, betel quid with tobacco and khaini are commonly used. These are major causative factors of tobacco-related cancers (TRCs). Smoking is posing a major problem in men, however, smokeless tobacco is quite widespread among both men and women. The WHO estimates that one out of two young people who start smoking and continue smoking throughout their lives will lead to TRC.
According to the International Agency for Research on Cancer (IARC) 1987, the anatomical sites of cancer that have been associated with the use of tobacco include lip, tongue, mouth, pharynx (including oropharynx and hypopharynx), esophagus, larynx, lung, and urinary bladder. According to IARC 2004 monograph vol 86, carcinoma cervix uteri, carcinoma kidney, myeloid leukemia, and carcinoma PNS are also said to be associated with TRC.
Objective and aim
Our aim is to highlight the incidence and pattern of TRCs with respect to all other sites of cancer in Kamrup urban district (KUD) for the year 2010–2014.
Population-Based Cancer Registry (PBCR) Guwahati covers the Kamrup district and was established in the Department of Pathology of Dr. B. Borooah Cancer Institute, Guwahati, in 2003 to estimate the incidence of cancer and pattern in KUD of Assam under the network of the National Cancer Registry Program (NCRP) of the Indian Council of Medical Research.
| Materials and Methods|| |
KUD has a total population of 1,179,405, out of which 608,844 are males and 570,561 are females for the year 2011. KUD covers an area of 701 km2, and population density is 581/km2. The data collected over the 5 years period of 2010–2014 are presented here.
Data collection is active with voluntary participation of different sources including major hospitals, diagnostic centers, state referral board, and birth and death registration centers within registry area as cancer is not notifiable in India. Coding is done as per the International Classification of Diseases for Oncology, 3rd edition. After series of quality checks, the data were entered in the software, PBCR Data Management provided by NCRP, Bengaluru, India. All checks specified by the IARC are included in this software.
The population of the registry area by age group and census was estimated using the 1991–2001. The crude rate, age-adjusted rate (AAR), and truncated incidence rates per 100,000 population were calculated by the direct method using the world standard population. Number distribution of estimated resident population by age and sex, KUD, for 2010–2014 is calculated using difference distribution method taking 2011 as a base year.
| Results and Observation|| |
In KUD, in males out of the total 4794 cases, 2386 cases were TRCs, and in females out of 3767 cases, 944 were TRCs for the period 2010–2014.
The proportion of aging population in both males and females is less than the younger population which is in contrast to that of developed countries.
According to the type of tobacco usage and the manner of its consumption, the incidence and relative proportion of specific sites of cancer varies. The findings reflect variations in pattern of tobacco use in males and females in KUD.
[Table 1] provides the number and relative proportion of sites of cancer associated with the use of tobacco as a whole relative to all sites of cancer in KUD.
From [Table 1], we see that in KUD, the relative proportion of cancers associated with the use of tobacco for males and females is 49.8% and 25.1%, respectively, when compared to all sites. The age-standardized rate (AAR) per 100,000 population of TRCs in males is 99.9 and in females is 48.0. Esophageal cancer alone contributes 14.5% in males and 10.4% in females to all cancer cases, followed by hypopharyngeal cancer 8.3% in males and lung cancer 4.5% in females.
A comparison of relative proportion (%) of TRCs relative to all sites of cancers of KUD (2010–2014) with other Indian PBCRs (2012–2014) is shown in [Figure 1] and [Figure 2] in males and females, respectively. In KUD, TRC comprised 49.8% of cancers in males and 25.1% of cancers in females.
|Figure 1: Relative proportion of tobacco-related cancers in India relative to all sites of cancers (2012–2014) in males|
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|Figure 2: Relative proportion of tobacco-related cancers in India relative to all sites of cancers (2012–2014) in female|
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The national comparison of incidence and patterns of AAR of esophagus cancer in male of KUD with all other PBCRs is depicted in [Figure 2], AAR of hypo pharyngeal cancer in male and female of KUD with all other PBCRs is depicted in [Figure 3] and [Figure 4], respectively. AAR of carcinoma of tongue in female of KUD with all other PBCRs is depicted in [Figure 5].
| Discussion|| |
Tobacco is the single greatest avoidable risk factor for cancer mortality worldwide. Deaths due to tobacco consumption will rise to 8–10 million by 2025, and smoking contributes to one-third deaths. Tobacco use in any form accounts for nearly half of all cancers among males and a quarter of all cancers among females in India. In the present study, we found that in men 50% (2386/4794) and in women 25% (944/3767) of all cancers were tobacco related. Head-and-neck cancer is common in the North Eastern Region of India, and high use of tobacco is a major risk factor for it.
[Figure 3], [Figure 4], [Figure 5], [Figure 6] show the national comparison of AAR of some tobacco-related sites in males and females of KUD (2010–2014) with all other Indian PBCRs (2012–2014).
Esophageal cancer in males has the highest AAR (71.2) in East Khasi Hills of Meghalaya state. Aizawl district has AAR (49.9). KUD has AAR (28.8). In females, the AAR of esophagus records highest in East Khasi Hills of Meghalaya state (33.0) while KUD records AAR (20.72). It is the major contributor of TRCs. Multifactorial causes are associated with it.
In hypopharynx, the AAR in males is highest in East Khasi Hills district (22.2), followed by Aizawl district (17.2). KUD is third highest AAR (16.0), while in females, KUD is leading with AAR (3.6), followed by Meghalaya state ((2.24) and Dibrugarh district (2.21).
Cancer of the tongue in females is second highest in KUD (3.5) after Bhopal registry (3.7), as seen from [Figure 7], while in males, AAR is 8.4 in KUD.
|Figure 7: International comparison of age-adjusted rate with that of population-based cancer registries in India – esophagus male|
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Cancer of the mouth, AAR: 9.7 in males and AAR: 7.3 in females in KUD are due to the use of smokeless tobacco may one of the risk factor.
Tobacco consumption is the major risk factor besides drinking alcohol, having bile reflux, drinking hot liquids, and low fruits and vegetables in diet. Among various risk factors for oral cancer in India, betel quid chewing carries a relative risk. Areca nuts fermented underground are contaminated with fungi such as Aspergillus flavus, Aspergillus niger, and Rhizopus sp. Aflatoxin, a fungal carcinogen, is responsible for a majority of human cancers which is known to contaminate tobacco products.
Various researches proved that cigarette smoking and other tobacco products represent a major source of human carcinogenic exposure. The association between cigarettes and lung cancer has been proven by large cohort studies. Smoking accounts for 80% of the worldwide lung cancer burden in males and at least 50% of the burden in females. This is reflected in the AAR in males 18.7 compared to females 8.19 in KUD. The risk of lung cancer development is 20–40 times higher in lifelong smokers compared to nonsmokers. Ninety percent of lung cancer deaths are attributable to smoking alone. The British doctor's study revealed that on average, cigarette smokers die about 10 years younger than nonsmokers.
[Figure 7] and [Figure 8] show the international comparison of incidence of AAR of esophageal cancers. China has the highest AAR (192.7) in males while KUD has AAR (28.8) and is in the ninth position following other northeastern registries, and in females, KUD has AAR (20.72) and is in the sixth position.
|Figure 8: International comparison of age-adjusted rate with that of population-based cancer registries in India – esophagus female|
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International comparison in hypopharyngeal cancer shows that KUD in females (AAR: 3.6) has the highest rank globally while in males (AAR: 16.0) has the third highest incidence rate [Figure 9] and [Figure 10].
|Figure 9: International comparison of age-adjusted rate with that of population-based cancer registries in India – hypopharynx male|
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|Figure 10: International comparison of age-adjusted rate with that of population-based cancer registries in India – hypopharynx female|
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The above data and GATS report show that TRCs (%) increase with a rise in the prevalence of tobacco use and pattern.
TRCs deserve a closure monitoring of incidence to prioritize the medical care resources and plan the cancer control programs. To reduce the use of tobacco, effective interventions are required to be implemented.
Steps for primary prevention such as awareness program, health education program against tobacco in schools and colleges, opening of tobacco cessation clinic, and arranging camps in various places to highlight the ill effects of tobacco should be taken. To strictly implement the Cigarettes and Other Tobacco Products Act (COTPA), 2003 that aims to prohibit smoking in public places, prohibit sale to minors, stop direct and indirect advertising. Increasing tobacco taxes is one of the most effective tobacco control measures leading to lower uptake and higher levels of cessation.
| Conclusion|| |
KUD in Northeast India is at a high risk of developing TRCs. This study of the incidence and pattern of TRCs in this region is of great importance in planning and implementing primary preventive measures of tobacco use.
We would like to thank Dr. Prashanth Mathur, Director, NCDIR, Bangalore, for financial assistance and technical guidance and all staffs of Population-Based Cancer Registry-Kamrup District.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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